Managing System-Driven Incidents—A Business and Performance Approach

Safety or the lack of safety is an outcome of human performance. Human performance creates the outputs of organizations in terms of products or services. Much of the output falls within an acceptable range, but some of it does not.

Those that do not meet the acceptability standard can be considered the
organization's operational "defect rate." The "defects" can be broadly
categorized as falling in the quality of the output (fitness for use) or the
efficiency of the process (such as waste generation, underutilization,
under-optimization, etc.), as well as damage, losses, or injuries the
workforce suffers. All of these result in some form of loss, which adversely
impacts the organization. Safety viewed as a human performance issue and the
factors that influence that performance and its resulting outcomes
constitutes a different perspective on safety and its management.

Traditional Safety Practices

Traditional safety management involves creating a program that, for the
most part, follows the Occupational Safety and Health Administration Safety
Standards. Such programs usually include a policy statement, a code of safe
practices, rules and regulations, accident investigation, training,
communication, meetings, inspections, and some form of reward/discipline
process. The bulk of the program generally is a restatement of the safety
standards as promulgated by the state in which the organization resides or
the federal safety standards. The more sophisticated organizations may add
additional requirements to this program based on past experience, specific
needs, or external requirements. These may include drug testing,
transitional duty work, vehicle driving requirements, behavior modification,
charge back systems, and cost allocations.

The safety process is managed primarily by looking at past results,
analyzing them, and using that information as a basis for future
interventions. This is a common practice in the industry at large. This
method works to some extent, but since the future is never exactly the same
as the past, this method can never eliminate all operational risk, and
therefore reaching zero injuries with this method is virtually impossible.
The traditional interventions in which companies typically engage fall into
three broad categories: engineering controls, training, and
audits/inspections. Virtually all safety standard and interventions as
promulgated by state or federal agencies fall into these three broad
categories.

Underlying all this is the general belief that safe work is controlled by
the worker. And it is the worker who ought to make sure that they perform
their tasks in such a manner so that they do not get hurt. This thinking
assumes that the worker is in total control. Nothing could be further from
the truth. Workers certainly should try to work safely and follow proper and
safe work practices. But they do not control much of anything except their
own actions. It is management who controls just about everything on site or
at the facility. Management plans the work, coordinates activities, assigns
the task, selects the workers, decides where the worker works, who they work
with, how fast they work, how long they work, what equipment they use, and
the list goes on and on and on. So, if we are going to find a solution to
our loss or injury problem, there is ample opportunity for this in the
management area!

Organizational Elements

Basically, most people work because they have to work. They work to make
money so they may support themselves. To accomplish this, most of them end
up working for some organization. The general goal of business organizations
is making a profit and generating value for stockholders and benefits and
salaries for management as well as for their employees. The organization
accomplishes this by producing a product or service that meets the needs of
others, who are willing to buy it. Some organizations may not have profits
as a goal, but they still provide something (a service) others need or want.

To produce the output, the organization has two key elements: systems and
people. The operational system may include plant, equipment, material
processes, procedures, and practices. And they have people to activate,
energize, manage, and control the systems so as to produce the outputs.
While the organization produces the outputs, it also produces or creates
some undesirable outcomes. On the product side, there is the issue of
quality. If it is below par, it may require rework or replacement. On the
production side, the undesirable outcome may be waste or inefficiencies. And
on the people side, it could be lack of motivation, involvement,
cooperation, support, sharing, and possibly injuries. All of these
undesirable outcomes ultimately generate waste, increase costs, and impact
profitability.

The operation is a subset of a larger system, which is the organization.
The organization also has two key elements, which are systems and people.
The people in the operations are the producers (workers), and the people in
the organization are the managers. The systems at the operational level
produce the output. The systems at the organizational level are the
policies, procedures, chain of command, resources, structure, metrics, etc.,
devised to effectively and efficiently run the operations to achieve the
organization's goals and objectives.

In the process of producing the output, which is desired, there are side
effects that are not value creating or desired. These defects are produced
as part of the output of the operating system. So, the question is, what
causes this model to generate the defects or undesirable outputs? At the
operational level, tools like lean thinking and Six Sigma can be used to
make the operational systems efficient; that is the easy part. "Fixing" the
people element is more complex and challenging.

Performance Management

We've already discussed how human performance is managed in the safety
arena and how it is usually less than optimal. In business, typically
performance is managed by setting goals and defining expectations for
employees. These goals may be set for production, quality, or some other
objective and possibly for safety
outcomes. Goals that are achieved may result in some form of feedback or
reward given to the employee by management, but sometimes that may be
delayed or none given at all. Failure, on the other hand, usually means the denial
of promotions, recognitions, or money. For workers who do not achieve the
expected goals, the organization may provide counseling, training, or some
other form of consequence.

Generally, these interventions or consequences are primarily directed at
the worker. In other words, the intent or goal is to "change" the worker,
while ignoring the fact that, in the operational model as described above,
there are two sources of failure risk: people and processes. Since producers
work within the system (interface with the system), the system influences
them and may cause them to take action, make choices, or arrive at decisions
that may results in errors or discrepancies and so lead to underachievement
or failure to meet expectations, to say nothing of the influence on the
worker by the organizational systems as well as management's actions,
prognostications, and behavior—and/or the worker's perception of these!

Human deficiencies, errors, or performance discrepancies are simply a
difference between an actual state and a desired state. Failure to meet
expectations is generally attributed to human failings (operator error) on the worker's part.
This may be attributed to inattentiveness, poor judgment, a lack of focus,
incompetence, negligence, stupidity, or worse—an intentional act. Such a
management outlook prevents digging deeper into the inner workings of the
organization for possible reasons causing such failure. This is one of the
major reasons why traditional safety performance improvement interventions
tend to have short-term effects.

It is important to note that all human deficiencies, errors, or
performance discrepancies do not result in catastrophic negative outcomes.
In many cases, the outcomes may be tolerable, have an inconsequential
impact, or even turn out to produce positive results. To understand failure,
we must also understand our reaction and response to failure. Workers do not
operate in a vacuum, where they can decide and act all-powerfully. To err
(underperform) or not to err is not a choice. Instead, people's work is
subject to, and constrained by, multiple factors that exist within
themselves, their perception, their motivation, the operational and the
organizational systems, as well the human dynamics.

If the worker is somehow "defective," that is, performing below
expectation, then it is possible that the hiring practices may have failed
in the selection process. Or the orientation of the worker may be at fault.
It may be that expectations were not clearly communicated. There may be a
mismatch between the worker's capabilities and the task demanded. These
shortcomings point to deficiencies in the organizational and management
systems and not necessarily to the worker. If the worker met hiring criteria
and somehow changed (for the worst) after being hired, then the reason for
the change (more than likely system driven) must be identified and dealt
with to alter the worker's performance, which is not what is typically done.

The Human Error Factor

The impact of human error on organizations is far reaching in terms of
productivity, customer service, quality, teamwork, decision-making,
execution, injury, and loss. There is little in terms of statistics for most
of these categories except for accidents. In many of the most serious
accidents in the past 50 years, almost all initial findings attributed the
failures primarily to human error. Examples include:

Little Rock, Arkansas, construction accident (1965)

West Virginia cooling tower collapse (1978)

Union Carbide Bhopal, India, disaster (1984)

Piper Alpha oil platform explosion (1988)

Phillips refinery explosion in Texas (1989)

Exxon Valdez oil spill in Alaska (1989)

Hamlet chicken processing plant fire in North Carolina
(1991)

Texas City BP refinery explosion (2005)

Crane accidents in New York City (2008)

BP Deepwater Horizon explosion (2010)

Referring back to the organizational model within which the operational
model exists, we identified systems and people (management) as sources of
risk. Management devises all the systems, and as humans are fallible,
creates systems with latent defects. Besides the system, management's
action, behaviors, and communicated expectations and prognostications
influence workers. The producers (workers) at the operational level have to
function within the systems as well as respond to management expectations.
Any latent defect, combined with operator perception actions or errors, may
lead to all kinds of failures.

The Systems-Human Interface

Management's intention is to devise efficient and effective systems, hire
capable workers, and manage the process so as to meet the organization's
goals and objectives. So why do we end up with less than desirable results?
If you think about it, in every realm of our lives, there are rules of
engagement. These rules apply at work, in our social life, and in our family
life. And, if we further think about it, these rules come in two varieties:
written and unwritten forms. The written rules are how we are supposed to
act, and the unwritten ones reflect the way we actually do act. Think of
this as it relates to safety. The written rules represent the safety
programs, the policies, procedures, training, etc., which are there to help
keep workers safe. The unwritten ones are the way workers actually act
and/or are expected to act, in spite of the written rules. So, why and how
do unwritten rules come about?

Safety management can be a much discussed and sometimes a misunderstood
topic. Over the years, many different theories and interventions have been
tried, and many of them have had less than stellar results. Some folks have
tried behavior-based safety; others have gone the systems approach path;
some would have you believe that safety should be management driven, while
others propose an employee-driven approach. There are also the metrics
issues in safety and how best to measure performance and success. All of
these approaches have been around for 15, 20, and even more years—so, why
haven't we hit on the "mother lode" of safety intervention as yet?

To run an effective organization, management sets out rules for how things
are to be accomplished, for without rules, there is chaos. These rules make
up the policies, procedures, and practices for accomplishing the
organization's mission and vision. Management also establishes a strategy to
make the organizational vision become reality. To accomplish the strategy,
management sets objectives, metrics, and targets. Management also interacts
with the employees on a daily basis through their statements, actions, and
behaviors. These actions and behaviors may not necessarily be aligned with
the written rules. These signals (management's actions and behaviors), along
with the written rules, interact with each other as well as other factors,
such as the employees' values, beliefs, expectations, agendas, etc., to
create "the organizational climate." The employees "read" this and determine
the best way to accomplish management's as well as their own goals and
objectives. These become the unwritten rules.

The unwritten rules help employees understand and cope as well as
successfully function within complex organizations. The unwritten rules tend
to have side effects. Some of the side effects result in positive outcomes.
They are unintended and unexplained, but at least they do not create
barriers to achievement or change. Other unwritten rules tend to be
undesirable from management's perspective and hamper accomplishment of
improvement or change initiatives. In safety, the undesirable side effects
are the incidents, injuries, and losses we see at our facilities and job
sites. Understanding the unwritten rules is more than just a way of removing
barriers to performance; it is a way to replicate success. The greater the
divergence between the written and unwritten rules, the larger to
organization's problem!

Let's look at some of the written and unwritten rules interactions and
resulting unwanted outcomes. Let us assume that a construction firm wants to
develop future project sponsors (managers). They may implement the
following rules to create a more rounded future management group.

Everyone must rotate though all the departments
(estimating, purchasing, cost control, scheduling, and field
operations) to better understand their workings and
relationships to other departments. This will normally take
about 24 months.

New talent will help improve the processes and practices
of the department, thereby improving the organization's
performance.

Fast learners can be promoted out of the department
earlier if the manager determines that the individual has a
good understanding of the department's functions.

Typically, departments are evaluated on their
performance and contribution to the bottom line.

Rules of intent:

Breadth of experience (learning)

Teamwork and innovation

Efficiency and process improvement

Accountability and superior performance

Obviously, this is a win-win for the employee as well as the
organization. But, how may the employee see these rules? As planned, it will
take 8 years or longer to become a project manager. So, to accelerate the
process, the individual must get the boss to promote him or her out of the
department as soon as possible. The individual may also determine that
innovative employees may be kept in the department longer as the department
head may want to achieve ongoing improvements to department functions and
results. Below is an example of possible unwritten rules the employees may
devise to achieve their goals.

Not contributing—Do not standout as an innovator and
therefore be retained longer.

Since departments are measured on performance—Watch the
quarterly reports so as not to be flagged as a nonperformer.

Avoid failure—Don't take any chances; limit
participation in teams that may fail.

Keep the boss happy—Do whatever it takes to stay on the
boss's good side to ensure promotion.

Doing so may produce the following outcomes:

Short term-ism

Poor team work

Lack of cooperation

Little or no innovation

This certainly was not management's intent, but it may result from not
looking at the proposed initiative holistically and understanding how
individuals may perceive and react to these rules. In construction, the
schedule (time) and budget (money) are key performance drivers and may
create unwritten rules that encourage risk taking. A worker may take risks
to keep his or her job if it is perceived that the supervisor values
production or achieving the day's production goal over safety work, even if
it involves taking shortcuts or not spending time planning as there is too
much to do in the allotted time. The list goes on.

Performance Improvement

We have looked at a number of opportunities to make performance
improvements in the safety function. The first was in the worker selection
process. We then looked at ensuring the worker has the capability,
knowledge, and motivation to perform the work effectively and safely. These
are the easier interventions. They more difficult performance improvement
opportunities lie in the understanding of the basic drivers of risk within
organizations that emanate from system design and operation.

One approach to eliminating or reducing the impact of some of the
system-driven risks may be to look at some of the core drivers of
organizational actions and behaviors such as the values, mission, vision,
and strategies. The first step is to list the business issues, performance
shortcomings, or barriers to improvement initiatives that cause the greatest
concern. The next step is to identify the unwritten rules that influence the
employees' behavior, resulting in the undesired side effects.

Three core underlying elements create the unwritten rules. The first is
what motivates the employees. Let's call these the motivators. What do the
employees want, value, and perceive as a reward or punishment? What is
important to them? Their behavior will be driven by what they want to
accomplish, achieve, or get. The next core element is who in the
organization can give the employee what they want. This generally is the
immediate supervisors, though it may be someone further up the chain of
command. This represents the power structure of the organization as
perceived by those within it. The third and final element is the trigger.
The trigger links the previous two elements. Triggers are the conditions
that must be satisfied so that the employees get what they want.

The process starts with a behavioral concern or problem, and by
understanding the three core elements that create the unwritten rules, which
in turn motivate and drive the employees' behavior, we are able to get at
something concrete that we can do something about. This analysis traces the
unwanted side effects to the corresponding written rule, thereby allowing
for a structural correction of the discrepancy and elimination of the
undesirable outcomes.

Conclusion

In safety, there are tremendous opportunities to apply the unwritten
rules concept to get at under-optimized safety performance. In safety,
strategy is deployed based on analysis of accidents and losses and the
implementation of "fixes," such as writing or rewriting programs, training
or retraining, inspections, and audits. None of these interventions analyze
why the employee engages in the unsafe activity and tries to address the
core drivers of that behavior.

Opinions expressed in Expert Commentary articles are those of the author and are not necessarily held by the author's employer or IRMI. Expert Commentary articles and other IRMI Online content do not purport to provide legal, accounting, or other professional advice or opinion. If such advice is needed, consult with your attorney, accountant, or other qualified adviser.

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